Hemophilia Case Review Form — Coverage / Authorization Intake
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This document is a Hemophilia Case Review Form used by providers and specialty pharmacies to request and document factor products, dosing, bleeding events, and dispensing details for members; it governs submission of information to the payer’s case review/authorization process.
No material clinical or coverage changes in this revision.
Coverage Criteria Summary
This document is an intake-style Hemophilia Case Review Form used to collect clinical and prescription details needed for case review and potential authorization. It does not itself define coverage criteria or exclusion rules; rather, it captures information such as product name, dosing instructions, number of doses/units requested, dates covered, treatment status, type of use (e.g., episodic, prophylaxis, acute bleeding episode, procedural prophylaxis), and place of administration to support the payer’s review.
The form does not list explicit not medically necessary conditions or formal exclusion language. Its scope is documentation and authorization intake: providers must complete the form in its entirety and submit supporting materials (for example, progress notes or bleeding diaries) to the payer for review rather than relying on the form to communicate covered versus non-covered services.
Provider Actions and Submission Requirements
Form completion and submission requirement
Complete the Hemophilia Case Review Form in its entirety and submit it with all required supporting documentation. The form must include dosing information (dose in IU), number of doses/units requested, total dose requested (IU), indication/type of use (episodic, prophylaxis, acute bleed, dental or surgical prophylaxis), dates/days' supply, place of administration, and any sig or special instructions. Fax completed form and attachments to 1-888-656-0841 or call 1-800-424-7892 for assistance.
- Include product name, dosing instructions, dose (IU) requested, number of doses requested, total dose requested (IU), and dates covered/days' supply.
- Indicate treatment status (treatment-naïve or treatment-experienced) and type of use (episodic, prophylaxis, acute bleeding episode, dental or surgical prophylaxis).
- Provide place of administration (home infusion, outpatient HTC, outpatient hospital, provider's office, self-administration).
- For specialty pharmacy dispensing, include vial strength, unit (IU) per dose, # of vials requested, units requested to dispense, total # of doses to dispense, total units requested, and explain any difference between prescribed and dispensed dose counts.
- For assay substitution when dispensing, the specialty pharmacy must attest that the assay(s) requested are the closest available to the prescribed dose (signature required).
Required documentation for case review
Providers must submit required documentation with the Hemophilia Case Review Form. Attach clinical progress notes, bleeding diaries, and any other relevant medical records that support the request. The provider is responsible for completing the form in its entirety and ensuring all supporting documents are included at time of submission.
- Attach recent progress notes documenting diagnosis, treatment plan, and clinical justification.
- Include bleeding diaries or event logs when applicable to document bleeding frequency/severity.
- For retrospective requests, clearly indicate retrospective status on the form and provide supporting records covering the requested dates.
Incomplete submission may delay/deny
Incomplete submissions — including an incomplete Hemophilia Case Review Form or missing supporting documentation — may delay processing or result in denial of the request. Ensure all fields on the form are completed and all requested attachments are provided to avoid delays.
- Missing dose, number of doses/units, total IU requested, or indication may result in request being returned or denied.
- Omitted progress notes or bleeding diaries will delay case review.
- If specialty pharmacy dispensing information or assay attestation is missing, dispensing may be adjusted or denied.
Background / Purpose of the Form
Background: The Hemophilia Case Review Form supports management of inherited and acquired bleeding disorders by documenting diagnosis, treatment intent, and event details to inform dispensing and utilization review. It collects provider and facility information, product name, dosing (including Dose (IU) and Number of Doses Requested), indication/type of use, and place of administration to assist specialty pharmacies and the payer in evaluating requests. Providers are instructed to complete the form fully and fax supporting documentation to the provided fax number or call the listed contact for assistance.
Key Definitions
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